By Alexandra Morell, MD
Synopsis: This unblinded, randomized clinical trial of patients undergoing minimally invasive benign nonurogynecologic hysterectomy with anticipated same-day discharge demonstrated that eliminating the requirement to void prior to discharge reduced time spent in the post-anesthesia care unit by 27.14 minutes (173.26 mins no void vs. 201.95 mins void; P = 0.002) without increasing the proportion of patients with postoperative urinary retention (3% void vs. 1% no void; P = 3.69).
Source: Le Neveu M, Davis J, Nicholson R, et al. Reevaluating the requirement to void following minimally invasive hysterectomy: A randomized controlled trial. Am J Obstet Gynecol. 2025;233(1):e11-e15.
The incidence of postoperative urinary retention (POUR) after minimally invasive hysterectomy is low, ranging from 0.2% to 7%.1 Anesthesia can affect the normal micturition pathways.2 Several perioperative factors have been associated with the development of POUR, including neurologic conditions that affect voiding (such as multiple sclerosis), the type of surgical procedure, aggressive intraoperative fluid resuscitation, and postoperative pain and opioid use. Historically, the ability to void spontaneously after surgery has been a requirement for discharge after minimally invasive hysterectomy.
This was an unblinded, randomized controlled trial at a single academic institution that investigated outcomes of a liberal voiding policy (eliminating the requirement to void prior to discharge) after minimally invasive hysterectomy among same-day discharge patients. Patients were included if they underwent a robotic or laparoscopic nonurogynecologic hysterectomy for benign indications during the study period and were planned for same-day discharge. Exclusion criteria included prior urologic procedures, neurogenic bladder, history of POUR, and concomitant nongynecologic surgery.
Patients were randomized in a 1:1 fashion to a void arm (required to void prior to discharge) or no-void arm (discharged after meeting all other postoperative milestones, other than voiding). Patients in the no-void group were contacted on postoperative day (POD) 1. All patients were contacted on POD 30. An algorithm for management of POUR was made. If patients contacted the on-call physician and had not voided within six hours of surgery, they were instructed to present to the emergency department. If a bladder scan demonstrated more than 500 cc of urine, patients were discharged home with a Foley catheter and followed up in the office in three days for a voiding trial. If patients had less than 500 cc of urine on bladder scan, straight catheterization was attempted with a re-attempt at voiding. If the patient still was unable to void within six hours or had a post-void residual (PVR) greater than 250 cc if voided within six hours, then they were discharged with a Foley catheter. The primary outcome was difference in post-anesthesia care unit (PACU) time. Secondary outcomes included time to void, rates of POUR, urinary tract infection (UTI), emergency department presentation, and hospital charges for PACU time.
Power calculations determined that a sample size of 200 patients was needed to achieve 80% power for the primary outcome. A total of 203 patients were included, with 102 randomized to the void arm and 101 randomized to the no-void arm. Roughly half of the patients underwent a robotic hysterectomy (51%). The mean age of the patients was 43 years and the mean body mass index (BMI) was 31.6 kg/m2. The most common indications for hysterectomy were abnormal uterine bleeding and fibroids.
Patients in the no-void arm were discharged, on average, 27.14 minutes earlier than those in the void arm (no-void 173.26 minutes vs. void 201.95 minutes; P = 0.002). However, there was no significant difference in the proportion of patients requiring longer than two hours in PACU between the two groups (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.20-1.10). There was no significant difference in rates of POUR (3% void vs. 1% no-void; P = 3.69) or diagnosis of UTI within 30 days (1% void vs. 2% no-void; P = 1.000) among groups.
On multivariable logistic regression, only robotic surgery (OR, 3.85; 98% CI, 1.35-11.00; P = 0.12) and younger age (OR, 0.92; 95% CI, 0.86-0.99; P = 0.29) were associated with PACU stays more than two hours. Lastly, the average cost of PACU care ranged from $6.26 to $7.19 per minute, so a reduction in PACU stay of 27.14 minutes could result in up to $194.13 in cost savings per patient.
Commentary
The American Association of Gynecologic Laparoscopists (AAGL) Enhanced Recovery After Surgery (ERAS) protocol provides recommendations for preoperative, perioperative, and postoperative care among patients undergoing minimally invasive hysterectomy to improve the outcomes and care of patients surrounding surgery.3 Postoperative recommendations from AAGL include discontinuing intravenous fluids when leaving the operating room, eating a regular diet after surgery, ambulating as soon as safely possible, using multimodal pain management with limited narcotic use, and following bowel regimens containing senna to decrease constipation. Removal of urinary catheters at the conclusion of surgery (unless there is an alternative indication for continued use) also is recommended.
The guideline notes that same-day discharge is feasible and safe after minimally invasive hysterectomy if patients are meeting anticipated postoperative milestones. Typically accepted criteria for same-day discharge include surgery end prior to 6 p.m.; expected blood loss; no intraoperative complications; normal vitals after surgery, with oxygen saturation more than 92%; patient alert and appropriately conversant; adequate pain control with oral medications; minimal nausea and no vomiting; ability to ambulate without assistance; and ability to void volitionally or a plan for continued catheter use at discharge.
Notably, certain patients should be planned for overnight admission, including those with poor social support following surgery, those who live a greater distance from the hospital, age older than 80 years, impaired cognition, impaired mobility, a history of anesthesia complications, and those with medical conditions that may affect postoperative recovery. This includes sleep apnea; poorly controlled asthma or chronic obstructive pulmonary disease; taking therapeutic blood thinners; having cardiac disease, type 1 diabetes, or poorly controlled type 2 diabetes; significant kidney disease with a glomerular filtration rate < 30 mL/min; or cirrhosis.
This study demonstrated that eliminating the need to void prior to same-day discharge among patients undergoing minimally invasive hysterectomy decreased the amount of time spent in PACU by approximately 30 minutes, resulting in a reduction in overall healthcare costs and without a significant increase in the incidence of POUR. It is important to note that this study excluded patients with known risk factors for urinary retention, such as prior pelvic surgery, neurologic disorders, and those undergoing surgery for pelvic organ prolapse or incontinence procedures. In addition, patients with gynecologic malignancies were not included. However, this study helps us rethink routine voiding requirements for same-day discharge after hysterectomy, especially in low-risk patients. Patients likely can be safely discharged if given clear instructions about when they need to void following surgery and if good follow-up protocols are in place in the case the patient is unable to void after discharge.
Alexandra Morell, MD, is Adjunct Instructor, Department of Obstetrics and Gynecology, University of Rochester Medical Center, Rochester, NY.
References
1. Gale J, Thompson C, Lortie KJ, et al. Early discharge after laparoscopic hysterectomy: A prospective study. J Obstet Gynaecol Can. 2018;40(9):1154-1161.
2. Agrawal K, Majhi S, Garg R. Post-operative urinary retention: Review of literature. World J Anesthesiol. 2019;8(1):1-12.
3. Stone R, Carey E, Fader AN, et al. Enhanced recovery and surgical optimization protocol for minimally invasive gynecologic surgery: An AAGL white paper. J Minim Invasive Gynecol. 2021;28(2):179-203.
